TTE 1st line in all suspected IE except in prosthetic valves or to assess IE complications where TOE 1st line.

Near zero risk (so no need for echo) if absence of:

  • Prosthetic valve
  • IVDA (drug abuser)
  • Embolic signs
  • Central line (so most ICU patients will have an indication if signs after admission)
  • Positive blood cultures
Irregular mass attached to upstream side of valve leaflet (atrial side for MV and TV).
Can be attached to any part of valve but most often at coaptation line.
Move with the leaflet but oscillate.
May prolapse through valve.
Fungal vegetations bigger than bacterial.

TTE has a sensitivity of 50% for detecting vegetations down to 2mm (misses 75% below 5mm).
Overall sensitivity TTE about 75% (absence does not exclude).
Specificity 95% (seeing vegetations with clinical suspicion means highly likely have IE).
High negative predictive value if completely normal study (IE very unlikely).

Describe by MELTS
Motion (independent of valve), Effects (regurg, abscess), Location (upstream, on prosthetic material), Texture, Shape.